DCH ApplicationThe Lancaster County Office of Aging assessment unit conducts face to face visits to determine an individuals functional needs and eligibility for the most appropriate type and place for services, including those seeking public funds to reside in a variety of long term care settings.

Requesting an Assessment

Use the Online Referral Form to request an assessment can be found on the Office of Aging Website. Select make a referral at the bottom of our page. Please provide as much information as possible, including name of person completing the form and their contact information. Please forward to the office by fax 717-295-2070 or by email to our office.

Forms Needed for a Nursing Facility Assessment

Medical Evaluation (MA51) Form

The MA51 form must be completed by the person’s physician and signed by the physician. Only a medical doctor can sign line 20A; it cannot be signed by a Certified Registered Nurse Practitioner (CRNP) or a Physician’s Assistant (PA-C). Instructions are posted with the MA 51 form (PDF). Sections to review for completeness are boxes

The following sections must be completed for the MA51 to be considered complete:

  • 7
  • 8
  • 9
  • Box 10 must be signed by the applicant or person acting for the applicant and dated
  • 11
  • 12
  • 13
  • 14
  • 20A, 20B, 20C


This is a required screening tool used for any individual being considered for admission into a nursing facility. The purpose is to identify individuals with serious behavioral health issues, intellectual or developmental disabilities, and/or related conditions to ensure they will receive appropriate services in the facility. The physician, social worker or an OOA assessor will complete the PASRR-ID form (PDF).

Fed Consent Form

Release of Information ( ROI)

The Assessment Process

Making a Referral

After receiving the referral for assessment, an OOA assessor will contact you to schedule the assessment visit. The visit must occur within 10-business days from the date the referral was received at OOA.

Incomplete Referrals

If referrals are missing documentation or the forms are incomplete the referral source will receive an email from our office letting them know what documents are missing or what needs to be corrected to process the referral as a complete referral. The time of the referral does not start until the completed referral is received. Below are the documents for each referral time that are needed at the time of the referral.

Referral Type



Release of information (ROI))

FED Consent Form 


Home and Community Based






Nursing Facility or Hospital






Personal Care Home





PCH Application

Domiciliary Care Home





DCH Application

The Assessment Visit

The assessor will ask questions using the Functional Eligibility Determination form (FED), focusing on the period 3-days prior to the assessment. This will give the assessor a picture of the person’s functional level and daily needs to determine the level of care - either Nursing Facility Clinically Eligible (NFCE) or Nursing Facility Clinically Ineligible (NFI).

After the Assessment

The Level of Care Notice will be provided to the nursing facility and to the County Assistance Office (CAO).

On day of admission to a nursing facility or at time of application, the application (PA600L) for Nursing Facility Medical Assistance is completed by applicant or family acting on behalf of the applicant and forwarded to the CAO. You will receive a notice regarding financial eligibility. All questions about the letter received from the CAO should be directed to the CAO caseworker listed on the letter.

OOA provides resources for nursing facility placement, however, does not contact nursing facilities on behalf of applicants. A list of facilities is available on our website or can be obtained by calling us at 717-299-7979 or 1-800-801-3070.

You will receive a separate notice with the outcome of the Level of Care (LOC) Assessment. That will come from the Department of Human Service’s Office of Long-Term Living (OLTL). If you have questions regarding the LOC Determination Notice, you may call the OLTL Participant Hotline at 1.800.575.5042 for assistance.

Under 60 Home & Community Based Service Referrals

For individuals under 60 who wish to apply for Home and Community Based Services, referrals must be made to the Pennsylvania Independent Enrollment Broker by visiting their website or by calling 1-877-550-4227. Results of assessments originating with PAIEB are automatically reported to PAIEB. If you have questions about your FED assessment result contact PAIEB at 1-877-550-4227. 

Personal Care Home & Domiciliary Care Home Assessments

Personal Care Homes (PCH/SSI Supplement)

PCH Supplement Application

Personal Care Homes are residences that provide shelter, meals, supervision and assistance with personal care tasks, typically for older people, or people with physical, behavioral health, or cognitive disabilities who are unable to care for themselves but do not need nursing home care. PCHs are inspected and licensed by the Pennsylvania Department of Human Services. Residents of PCHs do not require nursing care, so the appropriate LOC for them is Nursing Facility Ineligible (NFI).

The PCH resident or representative then completes and submits a PCH Supplement application and submits it to CAO. The Social Security Office and CAO determine if the individual meets the financial eligibility requirements for a supplement payment called the SSI Supplement to assist with the cost of PCH care. Questions about your eligibility for the PCH Supplement should be directed to the County Assistance Office at 717-299-7411.

Domiciliary Care (DCH/SSI Supplement)

Dom Care Supplement Application

Dom Care Homes provide a 24-hour supervised living arrangement in a homelike setting for consumers over the age of 18. An assessment is needed to determine if an individual meets a Dom Care Home Level of Care (NFI). An application is then completed and submitted to the CAO, and the determination is made by SSA and CAO whether the applicant qualifies for a supplemental payment to the Dom Care home. Questions about your eligibility for the DCH Supplement should be directed to the County Assistance Office at 717.299.7411

Additional Information

For additional information, contact our office at 717-299-7979 and ask to speak with one of our Information and Referral (I&R) Specialists. Due to call volume you could be asked to leave a message, and you will receive a return call. Please leave your name, phone number, email (if any) and who you are calling about, along with a detailed description of your concern.